Frailty Nurse

Job summary

Anexcellent opportunity has arisen for an enthusiastic and experienced frailtynurse to join our expanding clinical team at Parkbury House Surgery.

Theteam aims to deliver a service to individuals with complex and long-term healthneeds, to promote health and well-being, encourage and promote self-care andindependence, while aiming to avoid unnecessary hospital admissions andattendances. We aim to deliver this service in practice, in the patients ownhome or in a care home setting, dependent on the patients needs.

Aswell as developing and maintaining clinical skills to a high standard thesuccessful candidate will be expected to have skills and experience in other areasessential to the role such as long term conditions, dementia and frailty. Ideally,they would also be a prescriber with a minor illness qualification.

Thesuccessful candidate should be able to provide evidence based clinical carewith measurable standards and outcomes, aiming to improve care and quality oflife. The candidate should also have an awareness of up-to date local andnational guidelines in subjects relevant to the role.

Theyneed to be able to work as part of a team, supporting and complimenting theskills of the GPs, clinical pharmacists and other nurses to deliver a holisticservice to our patients. They also need to support and collaborate with the careteam in the care homes and the wider multidisciplinary team who have an inputinto the care of our patients.

Main duties of the job

The post holder is responsible for the delivery of a high-level skilland experience in other areas essential to the role such as long-termconditions, dementia and frailty. Ideally, they would also be a prescriber withminor ailment training and must be able to assess, plan, implement and evaluatecare for patients with a long term or complex frailty needs, recognisingindividual physical and psychological needs and observing the principles ofholistic care when planning treatment, which are sensitive to the ethnic,cultural and spiritual needs of the patient.

About us

Parkbury House surgery is a large and friendly, GP Surgery based in the centre of St Albans, with a branch surgery in Sandridge. We are a teaching / training practice of over 22,500 patients and deliver a high quality of care to our patients.

We are an 8 GP Partner led practice with a multi-disciplinary team consisting of GPs, Frailty Nurses, Practice Nurses, HCAs, Clinical Pharmacists and allied health professionals who are all supported by a large team of hard-working administrative staff.

All staff are very supportive in providing a good service for our patients. We received a GOOD from our last CQC inspection.

Job description

Job responsibilities

Clinical

To support the delivery of advanced nursing practice and services for older and or vulnerable patients at Parkbury House Surgery To be recognised as an expert in their field holding additional qualifications / specialist knowledge and expertise Provide Support and Care to patients with long term condition or complex frailty needs. Work as part of a practice clinical team (GPs, Clinical Pharmacists and the wider nursing team) to cover all a patients health care needs in a holistic way. Provide proactive care to patients within care homes covered by the Practice. This may take the form of a weekly visit to the home and also requests for home visits during the week. Providing specialist nursing advice and support to patients, their families and other healthcare professionals regarding frailty and admission avoidance. To work with patients, post discharge from hospital, ensuring that follow-up arrangements and admission avoidance plans are put in place. Promote health & wellbeing, self-care, and independence. Make relevant and appropriate assessments of patients physiological and psychological care and ensure defined needs are met through implementation, evaluation and necessary adjustment of care. To ensure continuity of a high standard of evidence based nursing care, assessing health, health related and nursing needs of patients, their families and other carers by identifying and initiating appropriate steps for effective care. To co-ordinate the multidisciplinary assessment of patients, providing detailed baseline patient assessment and education and support to patients and their families. To undertake regular medication reviews, focussing on polypharmacy and de-prescribing - within your limits and working with the GPs and clinical pharmacists. To liaise with community services, social services, paramedics and voluntary organisations in order to develop and make best use of existing services and pathways for patients, carers and health professionals. To be a highly visible and proactive frailty nurse, acting as a clinical resource and ensuring the sustained delivery of high standards of nursing care and service delivery. To be responsible for exploring current practice, identifying areas for development, and planning the appropriate change using current evidence to evaluate outcomes. To have expert knowledge in safeguarding processes

Managerial

Work collaboratively with the Frailty Team to lead on frailty to ensure that standards are delivered, and targets are achieved.

To be accountable for service delivery - in collaboration with the Clinical Lead and Frailty Team. Review performance information against service key performance indicators and lead on service delivery change where required.

In collaboration with the Clinical Lead and Frailty Team, ensure there are systems in place to learn from patient experience, risk and safety and outcomes information and develop systems of audit to ensure continuous improvement.

To work with the Practices allocated care homes and their staff to improve joint working and communication and quality of care for our care home patients.

To be a visible role model and leader to the wider Nursing and Medical teams.

Maintain own professional registration and practice within the NMCs Code of Professional Conduct and ensure the maintenance of professional standards within the Division.

Provide highly specialised advice on care and training relevant to frailty and the care of older people.

Service Development

To implement policies and procedures - propose changes to practice and operational processes.

To develop protocols relevant to frailty, including other disciplines as necessary.

Communications

Participate in research and audit and disseminate information and findings and lead on developments of advancing best practice.

Attend clinical governance and other multi-disciplinary meetings as required.

Communicate with patients, promoting involvement in the planning, delivery and evaluation of their care.

Liaise and communicate effectively with the multidisciplinary and wider community teams across health and social care.

Provide the highest standard of professional and expert clinical leadership.

Act as a role model and mentor for nursing colleagues and students.

Encourage staff members to utilise resources to attain and maintain high levels of medical and nursing care.

Non-medical Prescribing (if qualified)

Maintain relevant clinical and pharmaceutical knowledge, critically appraise and apply information in practice.

Consult with patients and their relatives / carers; generate treatment options and follow-up plans, where applicable.

Prescribe safely and effectively, acknowledging own limitations and scope of practice.

Work within practice policies that impact on prescribing practice.

To undertake regular audit and review, of prescribing practice and medicines management.

Access continuing professional development opportunities relating to Nurse Prescribing role.

Person Specification

Other requirements

Essential

Self-directed practitioner, able to work autonomously. Highly motivated Flexibility Enthusiasm Team player Ability to work across boundaries. Driver with car

Qualifications

Essential

Current NMC registration

Desirable

Post qualification certificates relating to appropriate aspects of this role Non-Medical Prescriber

Skills & Knowledge

Essential

Change management skills and ability to support patients changing their lifestyle Communication skills, both written and verbal Negotiation and conflict management skills IT skills Knowledge of needs of patients with long term conditions Aware of accountability of own role and other roles in nurse-led services Knowledge of health promotion strategies Awareness of clinical governance issues in primary care Knowledge of patient group directions and associated policy

Desirable

Phlebotomy Chronic disease management- asthma, COPD and diabetes Ability to identify determinants of health in the practice population Knowledge of the public health agenda focusing on general practice Awareness of local and national health policy Awareness of issues within the wider health economy

Other requirements

Essential

Self-directed practitioner, able to work autonomously. Highly motivated Flexibility Enthusiasm Team player Ability to work across boundaries. Driver with car

Experience

Essential

Management of long-term conditions Involvement in implementing and using protocols and clinical guidelines Experience of audit Minor illness Management of long-term conditions

Desirable

Experience working in a primary care setting Experience working with Older People Participation in quality initiatives, such as clinical benchmarking

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